Implications of NRHM in Punjab

Sustainable Health Development: An Analysis of Implications of NRHM in Punjab

Ms. Gunjan Malhotra[1]

Dr. Madhur M. Mahajan[2]

Abstract:

The National Rural Health Mission was launched in 2005 (although full fledged activities began in full swing in 2007-2008) along with other states and union territories. The thrust of the mission is on establishing a fully functional, community owned, decentralized health delivery system with inter-sectoral convergence at all levels, to ensure simultaneous action on a wide range of determinants of health such as water, sanitation, education, nutrition, social and gender equality.The paper intends to study the impact of NRHM in terms of health infrastructure and to examine the impact of NRHM on health indicators like Infant Mortality Rate, Maternal Mortality Rate and Total Fertility Rate in the state of Punjab. It also studies the differences in Punjab and Kerala in terms of Health infrastructure and Health indicators. The study results show that a number of sub centres, PHC and CHC have increased and also IMR, MMR and TFR have come down after implementation of NRHM. Sustainability in health development means improvement in the health indicators and better health care facilities for existing and future population.

Key words: NRHM, Sustainable Health Development, Mortality.

Introduction:

Health is described as the state of complete physical, mental and social well-being (WHO). Health is a state of being hale sound or whole in body, mind especially the state of being free from physical disease or pain. Good health is a pre-requisite for human productivity and development process. Improvement in health would make a positive impact on economic development. Better health can increase the number of potential man hours for production by reducing morbidity and disability as well as reducing mortality. Better health may result in more productivity per man as well as more men available for work.

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Promotion of a good health must be a prime objective of every country’s development programmes. The preamble to the WHO constitution also states that the enjoyment of highest attainable standard of health is a fundamental right of every human being and those governments are responsible for health of their people and they can fulfil that responsibility of taking appropriate measures.

“Sustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their own needs. It contains within it two key concepts:

• The concept of needs, in particular the essential needs of the world’s poor, to which overriding priority should be given; and
• The idea of limitations imposed by the state of technology and social organization on the environment’s ability to meet present and future needs.” (Brundtland Report, 1987)

Sustainability is related to the quality of life in a community — whether the economic, social and environmental systems that make up the community are providing a healthy, productive, meaningful life for all community residents, present and future. Sustainable health care system means meeting the health and health care needs of individuals and the population which would lead to optimal health and health care outcome.

According to WHO any policy is said to be sustainable when: It continues to function effectively for the foreseeable future, High treatment coverage, integrate into available health care services, have strong community ownership and use resources mobilized by community and government.

Taking into account the above factors of sustainability National Rural Health Mission was launched by the Hon’ble Prime Minister Dr. Manmohan Singh in New Delhi in 2005 in the country, with a special focus on 18 states. It recognizes the importance of health care in the process of economic and social development and improving the quality of lives of our citizens. It provides effective health care to rural population throughout the country. NRHM initiative as a whole with its wide approach is a national movement that just a national health project.

The main objective of NRHM in state Punjab is:

1. To provide accessible, affordable, accountable, effective and reliable health care, especially to the poor and the vulnerable sections of the population in rural areas.
2. To achieve health indicators like IMR, MMR and TFR to acceptable levels.
3. The mission is an articulation of the commitment of the government to raise public spending on health from 0.9% of GDP to 2-3% of GDP and aims to undertake architectural correction of the health system to enable it to effectively handle increased allocations as promised under the national common minimum program and promote policies that strengthen public health management and service delivery in the country.
4. To revitalize local health traditions and mainstream AYUSH into the public health system. It aims at effective integration of health concerns with determinants of health like sanitation and hygiene, nutrition and safe drinking water through a district plan for health.

Literature Review:

Kumar (2005) reported that study on Maternal Mortality Reduction and opportunity under National Rural Health Mission.Maternal Mortality Rate continues to remain high in our Country without showing any declining period of two decades. The proportion of maternal death contributes by direct obstetrics causes have also remained more or less the same in rural areas. There is a strong need to improve coverage of antenatal care, promote institutional deliveries and provide emergency of obstetric care.

Ramani (2006) “Status of Indian Health System” identified that the critical areas of management concerns in the Indian Health Care System are mainly non-availability of staff, weak referral system, poor service delivery, financial shortfalls and lack of accountability of quality of care.

Gautham (2007) in their study “Patterns of Public Health Expenditure in India: An analysis of State, and Central Health budget in Pre and Post NRHM Period” examined the size, distribution, trends, composition and rate of growth of Union and State Health Expenditure during the period of 2001 – 2002 to 2008 – 2009.

Garg (2007) explored the current status of implementation and progress of activities as envisaged under NRHM in the high focus states of the country that are under priority, as well as non priority states.

Ashtekar(2008) emphasised on the failure of decentralisation, the lack of inter-sectoral coordination, and the undermining of traditional health support are the reasons why the National Rural Health Mission has not delivered what it had set out to achieve.

Sinha(2009) studied that NRHM provided a large canvas and platform for health action, but Shyam Ashtekar (EPW, 13 September 2008) misses many issues and does not make his critique from the right perspective. During the short period of its existence there is ample evidence to show that the mission has been moving in the right direction, crafting a credible public system of health delivery starting from the village and going up to the district level.

Hussain (2011): reported that NRHM was introduced as a flagship scheme of the United Progressive Alliance government in 2005-06 to address the needs of the rural population through an architectural correction of the health system. With the completion period drawing to a close in 2012, he critically evaluates the success of the intervention strategies under this scheme.

Pal (2011) analysed NRHM, this programme has put rural public health care firmly on the agenda, and is on the right track with the institutional changes it has wrought within the health system. He seeks to evaluate the performance of service delivery in rural public health facilities under National Rural Health Mission. The concept and working of NRHM has been discussed in brief.

Anirvan (2012) in her study observed that National Rural Health Mission is the Government of India’s largest public health program. This report briefly analyse NRHM expenditures along the following parameters: overall trends in fund allocation and expenditure: GOI and States, allocation and expenditure on key programs like immunization, physical coverage and human resource avail- ability, and outcomes (Infant Mortality Rate and Maternal Mortality Rate).

Patra, Ramadass (2013) studied the impact of NRHM on the health infrastructure and on the health indicators and to analyze the determinants of health status in the health development of Odisha. The study is only based on the secondary data. The collected data was analyzed with the help of MS-WORD and Excel. The study showed that the health status of study area is very poor and is gradually increasing as a result of the implementation of NRHM and the staple reasons for this tendency are: low income, illiteracy, shortage of doctors, unwillingness doctors to go to remote areas and lack of health care facilities and lack of production of laboratory technicians and radiographers.

Thimmaiah, Mamatha (2014) intends to study the impact of NRHM in terms of health infrastructure and to examine the impact of NRHM on health indicators, like Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR), Crude Death Rate (CDR) and Total Fertility Rate (TFR) in Karnataka. The study result shows that the number of Sub Centres, Primary Health Centres and Community Health Centres has increased between 2005 and 2010. Also, IMR, MMR, CDR and TFR have come down after the implementation of National Rural Health Mission.

Objectives of the study:

• To study the impact of NRHM in terms of health infrastructure in Punjab.
• To examine the impact of NRHM on health indicators like IMR, TRR and MMR in Punjab.

Hypothesis of the study:

There is significant reduction in health indicator IMR, MMR and TFR after implementation of NRHM.

Methodology of the study:

Keeping the objective of the study into mind, an attempt has been made to draw a comparative picture of the health indicators before and after NRHM. The study relies on secondary data. The data is collected from Ministry of Health and Family Welfare statistical report NRHM, statistical abstract of Punjab, NRHM Annual Reports, Five year plan reports, Economic survey, Census reports and WHO reports. The data collected has been tabulated and impact of the NRHM on sustainable health in Punjab has been gauged by employing graphical analysis, correlation techniques and t-test.

Impact of NRHM in terms of Health Infrastructure in Punjab

Table 1: Number of Sub Centres, PHC’s and CHC’s functioning

Source: Economic Survey 2012

From the above table it is clear that in the year 2005 when NRHM was launched, there were 2850 sub centres, 441 PHC’s and 120 CHC’s operated in Punjab. In the year 2010, the number of sub centres, PHC’s and CHC’s increased to 2950, 449 and 132 respectively. At all India level the PHC’s, CHC’s and sub centres have increased.

In the following chart it is found that Sub Centres, PHC’s and CHC’s have been increased from the year 2005 to the year 2010 after the implementation of NRHM in Punjab.

Chart-1 Sub Centres, PHC’s and CHC’s in Punjab

Impact of NRHM in terms of Health Indicators in Punjab

To study the impact of NRHM in terms of health indicators 3 indicators are used which are Total Fertility Rate (TFR), Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR). A time period from 2000 to 2011 has been taken 6 years before implementation of NRHM and 6 years after NRHM.

The following table shows the health indicators from 2000 to 2011:

Table-2 Health Indicators 2000-2011

Source: RHS bulletin 2012(health and family welfare in Punjab)

From the above table it is clear that IMR, MMR and IMR have reduced over the time period 2000 to 2011. Before implementation of NRHM, TFR was 2.4 and has been reduced to 1.7, MMR was 178 has been reduced to 154 and IMR was 52 has been reduced to 28.

Chart-2 TFR 2001-2013

The above charts shows the decline in Total Fertlity Rate from 2000 to 2012 and the current rate is 1.7.

Chart-3 MMR 2001-2012

The chart 3 shows a decline in Maternal Mortality Rate but in the year 2004-05 there has been increase in MMR and thereafter a decline in MMR.

Chart-4 IMR-2001-2013

Chart-4 shows a significant decline in IMR after the implementation of NRHM. As compared to other health indicators IMR has shown the maximum improvement.

Table-3 Sample t-test on Health Indicators in Punjab

On the basis of analysis conducted by using sample T-test indicates that TFR was 2.28 before implementation of NRHM and it was decreased to 1.865 after implementation of NRHM. Overall decreased rate is 0.4183. The t statistic is significant at 1% level of significance. Hence null hypothesis of no difference is rejected and alternative hypothesis of significant difference is accepted.

With respect of MMR, the rate of MMR 48.83 before implementation of NRHM and it was decreased to 163 after implementation of NRHM. Overall decreased rate is 19.34.The t statistic is significant at 1% level of significance. Hence null hypothesis of no difference is rejected and alternative hypothesis of significant difference is accepted.

With respect of IMR, the rate of MMR 182.34 before implementation of NRHM and it was decreased to 35.67 after implementation of NRHM. Overall decreased rate is 13.16.The t statistic is significant at 1% level of significance. Hence null hypothesis of no difference is rejected and alternative hypothesis of significant difference is accepted.

Major Findings of the Study:

1. Number of sub centres, PHC’s and CHC’s have increased from 2005 to 2010 after the implementation of NRHM.
2. Over the period substantial reduction has been seen in IMR, MMR and TFR after the implementation of NRHM.
3. The reduction in the indicators and increase in health infrastructure depicts that there is sustainability in health after the implementation of NRHM.

Conclusion:

NRHM launched by the government of India holds great hope and promises to serve deprived communities of rural areas. The invariable existence of social cultural differences in the community has always been a challenge to health care efforts made by Government of India. Sustainibility in health is a major challenge in the hands of Government i.e. reduction in major health indicators and improvement of health infrastructure without having an effect on future generations. Sustainibility has a very wide scope and there are many reasons and policies which emphasis on Health Infrastructure and Health Indicators. But this paper only studies the impact of NRHM on the sustainibility of Health Development in Punjab.

Refrences:

1. Ashtekar, S (2008): “The National Rural Health Mission: A Stocktaking”, Economic & Political Weekly, XLIII (37): 23-26.
2. Anirvan Chowdhury, (2012) in her study “Budget Briefs-National Rural Health Mission”, Accountability initiative Research and Innovation for Governance accountability, No 69.
3. Garge Suneel, Natha Anita, (2007) “Current Status of National Rural Health Mission”, Vol.32, Issue: 3 page: 171-172.
4. Kumar’s “Challenges of Maternal Mortality Reduction and Opportunities under National Rural Health Mission. A Critical Appraisal”, Indian Public Health. 2005 Jul-Sep; 49(3): 163-7.
5. Ramani K.V, Maavalakar Dileep, (2006) “Health System in India: Opportunity and challenges for improvement”, Journal of Health and Organization Management, UK, Vol. 20, No 6, PP 560-572.
6. Suresh Kumar Patra, L.Annam & Prof. M. Ramadass (2013) “National Rural Health Mission (NRHM) and Health Status of Odisha: An Economic Analysis” Language in India ISSN 1930-2940 13:4 April 2013.
7. World Health Organization. 2006. Constitution of the World Health Organization – Basic Documents, Forty-fifth edition, Supplement, October 2006.
8. Husain (2011) “Health of the National Rural Health Mission”, Economic and Political Weekly, Jan 22, vol XLV1, No 4.
9. Pal (2011) “National Rural Health Mission: Issues and Challenges”, Zenith International Journal of Business Economics and Management Research, Dec 2011, Vol.1 Issue 3.
10. Thimmaiah, Mamatha (2014) “National Rural Health Mission Status in Karnataka: An Economic Analysis”, ISSN-2250-1991, Vol.3 Issue-5.
11. National Health Systems Resource Centre “NRHM in Eleventh Five Year Plan”, ISBN-978-93-82655-00-8.
12. http://www.punjabstat.com/health/16/vitalstatistics/291/infantmortalityrate/17794/stats.aspx
13. http://www.pbnrhm.org/home.htm

[1] Assistant Professor, Post Graduate Department of Economics, GGDSD College, Chandigarh.

[2] Assistant Professor, Post Graduate Department of Economics, GGDSD College, Chandigarh.